Design and Implementation of a Clinic-Based Food Pharmacy for Food Insecure, Uninsured Patients to Support Chronic Disease Self-Management

Each food package contained fresh produce and shelf-stable foods selected by the project's dietitian in collaboration with food bank staff. Foods aligned with the Dietary Approaches to Stopping Hypertension diet, which was also suitable for patients with diabetes. The food package was designed to supplement a patient's monthly food supply and contained a rotation of items representing foods featured in the curriculum and recipe cards. Each shelf-stable monthly package included 16–30 servings of beans, 5–16 oz nuts and seeds, 4–13 servings of no-sugar added dried fruit, 48–64 oz low-sodium vegetable juice, 14–30 servings of whole grains, 17 oz olive oil, 7.5–14.75 oz canned fatty fish, and 1–3 anti-inflammatory spice containers (0.65–1.1 oz each) (Figure 1). Each box was valued at $40 and purchased for about $24 through the food bank's reduced-cost ordering program.

The Food Pharmacy curriculum included an orientation booklet that provided an overview of healthy eating principles for cardiometabolic disease, including essential information about how food choices relate to blood pressure, lipids, and blood sugar, which were further reinforced through sample low-cost, easy-to-prepare recipes that accompanied each food box. Medical student clinic interns drafted booklet content and 7 sets of recipe cards (35 in total) that were informed by the Dietary Approaches to Stopping Hypertension diet guidelines and illustrative of food box items. The booklet and recipe cards were reviewed for accuracy and further adapted for the needs of resource-limited populations by a registered dietitian with advance-practice certification in clinical nutrition and previous food banking experience. The final curriculum received additional peer review by a physician at 1 of the clinic test sites. The booklet covered 6 topics: (1) anti-inflammatory spices, herbs, and teas; (2) phytonutrients and high-potassium fruits and vegetables; (3) low-cost, plant-based protein foods; (4) whole grains; (5) healthy fats; and (6) dairy alternatives and low-fat dairy. Essential information for each topic was written at less than an eighth-grade reading level and combined with straightforward action steps, illustrative pictures, white space, and a section for patient goal setting and confidence assessment (Figure 2). Recipes were written at or below a sixth-grade reading level, pretested by medical student interns, incorporated food pharmacy foods, contained <5–7 ingredients, and used basic kitchen appliances and cooking techniques. Sample recipes include salmon hash, low-sodium vegetable soup, sardine patties, and lentil pasta sauce.

Eligible participants included any patient accessing 1 of the 2 test site clinics who either self-enrolled in the program or was identified for the program by a health care or social work provider. Upon enrollment, participants received an initial food package, the educational booklet, and 5 recipe cards during the medical appointment. Medical and social work students who received training in the curriculum by the project's dietitian oriented patients to the booklet and sample items from the food box. Participants were eligible to receive another food package during clinic hours 6 additional times with visits limited to once per month. Before each week's clinic, the project coordinator provided reminder calls to patients who were eligible for another food package. The food bank delivered shelf-stable foods monthly, which were stored on-site, and produce weekly before clinic hours for immediate distribution.

Project staff collected informal feedback from participants during each visit about their use of food box contents and recipe cards from the previous visit. For example, low-sodium vegetable juice was well received but participants strongly preferred vegetable juice in 8-oz cans instead of a 64-oz bottle. Few participants reported eating the canned sardines, so canned salmon or tuna was included in subsequent boxes.

At baseline and upon the fourth visit, the researchers administered standardized surveys to collect demographics and used validated measures of dietary intake and food security status to evaluate outcomes reported here, including the Block Fruit/Vegetable /Fiber Screener, the 6-item Short-Form US Household Food Security Survey Module, and items from the Hunger in America 2014 Study. Blood pressure data were obtained through medical record review.